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• San Joaquin County • 1868 East Hazelton Avenue <br /> Stockton,CA 95205 <br /> Environmental Health Department Tel: (209)468-3420 <br /> Fax: (209)464-0138 <br /> BODY ART FACILITY AND PRACTITIONER REGISTRATION/ <br /> MECHANICAL STUD AND CLASP EAR PIERCING NOTIFICATION <br /> I. PROCEDURES TO BE PERFORMED:Check all that apply (see back for definitions) <br /> ®Tattooing ®Body Piercing r7mechanical Stud and Clasp Ear Piercing <br /> Branding Permanent Cosmetics <br /> II. REQUIRED REGISTRATION, PERMIT,OR NOTIFICATION FEES:Check all that apply. <br /> 1[MAnnual Body Art Practitioner Registration 3MMechanical Stud and Clasp Ear Piercing Notification <br /> 2�Annual Body Art Facility Permit <br /> III.APPLICANT INFORMATION: <br /> NAME: 'Sw�VLL VVxce 0S Phone: :20-ri 3L 7'1363 <br /> f_ tt����, <br /> HOME ADDRESS: 12-65- Kc-4ZQ 9 -AvI 1 JC'-V Email: AVrn+CIi,a-sixty-fc1AQJ&lcthojx ar—,w? <br /> 1. <br /> '% <br /> City: Lod t State: C A Zip: Zy 2 County: jc>oxi t oyi � <br /> a <br /> Date of Birth: V - (6-- /q 7H Gender: M or M (circle one) <br /> Identification Type: PRIDrivers License MOther Identification No.: �( 7 yV <br /> Facility where Boody Art Services Will be Prodded ) <br /> FacilityName: Avxc�o,-S /'/�16t w �ci+o6 Owner: ka k e LA)j "Ct V1-5 <br /> Address: 0 EK !C fA 114 L P1 <br /> I_Ja t C 14 Zj ! 2 40 <br /> Evidence of Six-mo the of Related Experience h <br /> FacilityName: 0. R Won Owner: ✓lGi ,e Lj 14,ti <br /> Address: E Bye 1-m Lail' �ZYa <br /> Service You Provided: o ( zi <br /> Supervisor Name and Contact Information: 51ck iK-5 2-09-139-q l'10 <br /> Bloodborne Pathogen Training: Submit Certificate <br /> Date Com leted: 0,0-6 ZG I z- Training Provided by: o LNU e- <br /> Hepatitis B Vaccination Status: Choose One and Submit Documentation <br /> IMCertification of Completed Vaccination 3MContraindicated for Medical Reasons <br /> 2=Laboratory Evidence of Immunity 4QVaccination Declination <br /> IV. FACILITY LOCATION (S):(Attach additional sheets as necessary) <br /> 1. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/Fax: <br /> 2. BUSINESS NAME: <br /> Location address: Suite: <br /> City: State: Zip: County: <br /> Owner/Contact: Phone/Fax: <br /> The undersigned hereby applies for a Body Art Facility Permit and/or Practitioner Registration and/or Mechanical <br /> Stud and Ear Piercing Notification and agrees to operate in accordance with all applicable state and local <br /> requirements governing safe body art practices or practices governing mechanical stud and clasp ear piercing. <br /> I hereby certify that to best of my knowledge and belief the statements made hein are true and correct. <br /> Signature: Date: -1111712, <br /> Print Name: ^�µ 11nC� Title: Owk t,^ I'Ta A <br /> r <br /> flf <br />